Industry and Government Should Increase Awareness of Warning Signs That Could Avert Disasters

In the aftermath of catastrophes, it is common to find missed signals and dismissed alerts that, had they been recognized, could have prevented a disaster. The task facing companies and government agencies is learning how to recognize and act on these signals before the event happens.

Organizations that run facilities ranging from hospitals to factories to power plants should step up their efforts to collect and use information on accident precursors, says a new report from the National Academies' National Academy of Engineering. Initiatives to gather and use this information are currently pursued by only a small fraction of the companies and agencies that could benefit from such programs.

Nationwide, organizations in high-hazard industries should establish programs to detect accident precursors, evaluate their causes, and implement corrective actions, the report says. Several types of programs, such as reporting systems for near misses and surveillance systems that detect precursors automatically, are highlighted in the report. By implementing such programs, an institution can increase employees' awareness of what can go wrong and provide impetus to address hazards, the committee added.

Companies should work to overcome barriers that deter employees from reporting precursor events, the committee said. For example, many organizations could do a better job of encouraging the reporting of near misses. "Near misses are helpful, inexpensive learning opportunities from which to analyze what could go wrong," said Howard Kunreuther, co-chair of the committee that wrote the report and professor of decision sciences and public policy at the Wharton School, University of Pennsylvania, Philadelphia. "Unfortunately, in many cases individuals may not report near misses because they worry that they will be blamed for what occurred."

Precursor programs are increasingly being adopted in aviation, aerospace, chemical, nuclear, and health care industries. But existing initiatives are not always as effective as they could be. "Even in programs that are successful in gathering precursor information, significant obstacles can prevent organizations from fully learning from these events," said Vicki Bier, co-chair of the committee and professor of industrial engineering at the University of Wisconsin, Madison. "Organizations need to filter precursor information to identify events that expose unacceptably high risk, determine root causes and corrective actions, share information with appropriate stakeholders, and implement and monitor steps to reduce risk."

Government agencies should develop policies that encourage the use of precursor management approaches and recognize which existing approaches could be applied to various other institutions, the report says. Examples of programs worth emulating include the Accident Sequence Precursor Program, overseen by the Nuclear Regulatory Commission; the Aviation Safety Reporting System, overseen by NASA; and the Aviation Safety Action Programs, administered by airline carriers according to guidelines set forth by the Federal Aviation Administration. Also, the report encourages government agencies that regulate high-hazard industries, as well as agencies that support fundamental research, to increase their support of research into methods for effectively analyzing and managing precursors.

The study was sponsored by the National Science Foundation, Public Entity Risk Institute, Nuclear Regulatory Commission, and NASA. The National Academy of Engineering is a private, nonprofit institution that provides technology advice under a congressional charter. A committee roster follows.